Pediatric Case Report Pyourachus in Spina Bifida: Case Report and Review Shiva Sarwan and Barbara Rampersad Failure of the urachus to close results in a multitude of clinical anomalies. Such anomalies have been documented as occurring in association with mechanical bladder outlet obstruction. However, no urachal anomalies have been linked specifically to spina bifida. Two cases of urachal abscesses were identified in adolescent male patients with spina bifida at our institution, both with neuropathic bladders and using self-catheterization. The clinical presentations differed, with classic involvement of the umbilicus in 1 case. Because of its varied presentations, the diagnosis of a urachal anomaly is potentially difficult. Urachal anomalies should be considered in the evaluation of pelvic masses in this demographic. UROLOGY 80: 427– 429, 2012. © 2012 Elsevier Inc. C ongenital spinal anomalies are associated with distortion of the spinal cord and can result in an array of neurologic abnormalities, including neu- ropathic bladder dysfunction. 1 Clinically significant urachal anomalies are rare, and most occur in early childhood and adolescence. 2 Urachal anomalies have been documented as occurring in cases of congenital lower urinary tract obstruction. A persistent urachus infrequently coexists in patients with a posterior urethral valve with high intravesical pressures, serving as a protective renal effect by way of a “pop off” mecha- nism. 3 A review of databases, such as MEDLINE and PubMed, and on-line searches revealed no association of urachal anomalies with spina bifida. We recently encountered 2 cases of urachal abscesses occurring in adolescent male patients with spina bifida cystica with neuropathic bladder and suggest a link be- tween the 2 pathologies. CASE REPORT Case 1 A 12-year-old boy with repaired spina bifida presented with a 3-day history of a painful lower abdominal swelling with cloudy urine. On examination, a 20-week pelvic mass reaching up to the umbilicus was noted, with an everted erythematous umbilicus with a purulent discharge. Abdominal ultrasonography revealed a 9 cm  7 cm  6 cm heterogeneous pelvic solid mass arising from the superior wall of the urinary bladder with bilateral hydro- nephrosis, the left greater than the right, and hy- droureters and a thickened bladder wall. Computed to- mography of the abdomen, a noncontrast study, confirmed a cystic lesion anterior to a thick-walled uri- nary bladder (Fig. 1), extending proximally to the everted umbilicus (Fig. 2), consistent with a urachal abscess. Emergency drainage revealed a large abscess cavity in the abdominal wall extending from the umbilicus supe- riorly to the bladder inferiorly and containing 300 mL of pus, which grew Escherichia coli on culture that was sen- sitive to trimethoprim-sulfamethoxazole. A midstream urine sample yielded the same results. A staged deroofing of a urachal cyst was performed after the infection had cleared. A 4-cm cystic, nonpuru- lent cavity was found that was adherent to the bladder dome in the inferior aspect of the abdominal wall. No tract was found extending to the umbilicus. The cyst was deroofed and curetted. At laparotomy, midstream urine grew 100 kcol/mL of Klebsiella pneumoniae and the cystic fluid grew occasional K. pneumoniae, both sensitive to ceftriaxone. Histologic examination showed a cyst wall lined by inflamed granulation tissue and blood. The wall was composed of fibroadipose tissue that also showed inflam- mation with microabscesses. The features were consistent with an inflamed urachal cyst. Case 2 A 13-year-old boy with a neuropathic bladder secondary to spina bifida and bilateral hydronephrosis and hy- droureter, using clean intermittent self-catheterization, presented with a 4-day history of lower abdominal pain. Examination revealed a firm, tender, 20-week pelvic mass reaching up to the umbilicus, with a normal umbilicus. Emergency urinary catheterization yielded purulent urine. However, a residual mass of 20-week size persisted after catheterization. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Pediatric Surgery, Eric Williams Medical Sciences Complex, North Central Regional Health Authority, Champs Fleur, Mt. Hope, Trinidad and Tobago Reprint requests: Shiva Sarwan, M.B.B.S., Department of Pediatric Surgery, Eric Williams Medical Sciences Complex, North Central Regional Health Authority, Champs Fleur, Mt. Hope, Trinidad and Tobago. E-mail: shiva_2209@yahoo.com Submitted: November 23, 2011, accepted (with revisions): January 16, 2012 © 2012 Elsevier Inc. 0090-4295/12/$36.00 427 All Rights Reserved doi:10.1016/j.urology.2012.01.021